Tuesday, February 12, 2013

1288. Follow up oro-nasal fistula 6 years later

tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS

Date: 13 February, 2013
Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
A Facial Wound does not heal: Oro-nasal fistula follow up 6 years later Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: November 15, 2007
Update: 13 February, 2013
Be Kind To Pets
Veterinary Education
Project 2013-0131
Wound for many months. Oronasal fistula. Maxillary PM4. Toa Payoh Vets"Why didn't you come for the surgery?" I admonished the lady owner of the Pomeranian. "You wasted more money buying more antibiotic powder from the pet shop to dust onto the facial wound, hoping it would heal.

"For ordinary skin wounds, the antibiotic powder would heal them, but I had already explained to you why the wound would never heal without dental extraction of the infected tooth."
Her 4-year-old Pomeranian had a weeping wound of around 0.5 cm in diameter below the left eye, above the maxillary 4th premolar tooth. It did not heal over the past weeks despite various medications and powders she had sprinkled on.
Some 14 days ago, I had patiently explained to her by illustration how the infection from the root of the maxillary 4th premolar spread into the nose from the diseased gums to the skin below the eye.

The bacteria from the decayed roots of this premolar had dissolved the nasal bone area and made a hole. This condition is called an oro-nasal fistula. Dental surgery to remove the infected premolar would resolve her Pomeranian's non-healing wound problem once and for all.

"The vet did a slick sales presentation to make me spend money unnecessarily" the husband of the dog owner must have told her. "How can a rotten tooth inside the mouth cause a hole on the skin below the left eye. This doctor is nuts and is desperate to make money. Mouth and nose. So far apart. How can there be a connection?"

Back to the present, I said, "Surgery was to be done 7 days ago after 7 days of antibiotics. But you did not turn up till today --- 14 days later!"

The middle-aged lady shook her head. I forgot my bedside manners by scolding her. The customer is king. The general anaesthesia and tooth surgery was affordable for her as I had discounted my fees but that money could buy another sari from Niven Road's sari shop.

I was annoyed because there was an optimal time to do extraction of the infected and decayed tooth. It was after 7 days of antibiotics and she had not kept her appointment nor cancelled it. She just did not turn up as there was less weeping of the wound due to antibiotics. However after the course of antibiotics, the bacteria in the infected teeth had resumed their attack and the facial wound became wet again.

The lady pulled up her fine and most colourful sari and smiled sheepishly, "My husband wanted to use the money for the dog's anaesthesia and surgery to go to India for holiday lah!"

Now that the dog is no longer on antibiotics, should I operate? There was no urgency in the sense that it was an emergency. But it would be in the best interest of this poor dog to be cured as soon as possible.

The Pomeranian's teeth were not brushed at all as this is a common practice in Singapore.

Initially bacteria attacking the food debris on the tooth gum line would die in 3-5 days to form a plaque on the tooth surface. As the dog's teeth were not brushed daily or at all, more plaque accumulated on the surface of the teeth.

Soon they become tartar (calculus). The gum became infected, leading to gingivitis. The root of the 4th premolar tooth of the upper jaw became abscessed due to bacterial attack. Abscess tracked upwards towards the nose and side of the face. Soon a facial wound appears to form a connection (oro-nasal fistula) between the tooth and the skin, discharging pus daily. As the pus and fluid from the mouth is discharged daily, the wound can never heal as it is always infected.

The decayed 4th premolar and lst molar became loose as their roots had been exposed as the diseased gum diseased shrivelled. The supporting structure of the teeth was weakened by the bacterial attack, leading to a loose tooth that would fall out in time to come.

At this time, there was no choice but to extract these two loose teeth. Otherwise the Pomeranian would suffer from daily toothache as the owner's husband might thwart her from doing the right thing for her dog. I put the Pomeranian under general anaesthesia gas and got the offending teeth extracted and scaled the other good teeth to remove the tartar.

Pom Oronasal fistula, premolar 4 root infection, Toa Payoh Vets "How can a rotten tooth inside the mouth cause a hole on the skin below the left eye? So far away. This doctor is nuts and is desperate to make money." the husband must have had advised his wife. "The money is better spent travelling."

So, at first, she did not heed my advice to do extract the infected premolar No. 4. The facial wound just would not heal and it cost her time and money to apply medication with no good outcome
Pom Oronasal fistula, premolar 4 root infection, Toa Payoh Vets The facial wound closed after a few days when I phoned the lady owner to follow up after extraction of the infected teeth. "You are a good vet," the lady surprised me with her compliment especially after my admonishment.

She needed not clean the wound daily and her dog was more active and has a livelier demeanour. And what more joy could a lady have than to see her companion having a higher quality of life?

BLOOD TEST & OTHER PROCEDURES. There was no pre-anaesthetic blood tests to assess the liver and kidney functions and blood cells of this younger Pomeranian. Veterinary costs would be additional $150.
Most likely the poor Pomeranian would not receive any veterinary attention if an increase of $150 was added to the veterinary expenses. Therefore I did not require blood tests and had reduced costs in not prescribing pain-killers and pre-op i/v drip and antibiotics.

Physical examination of the Pomeranian indicated that there was no cardiac problem and there should be no death from general anaesthesia. The dog's anaesthesia was uneventful. He went home on the same day and had no more facial wound below the eye as the cause was removed.
I have not seen the Pomeranian since 2007. He was 4 years old then. In Feb 2013, the owners came with the Pomeranian wanting to board the dog for Chinese New Year. I took the following image of him with a face that has no more oro-nasal fistulas for the benefit of readers.

This webpage:

More interesting cases of dental problems in Singapore dogs:
Toa Payoh Vets Clinical Research: Mouth problems in Singapore's dogs
tpvets_logo.jpg (2726 bytes)Toa Payoh Vets
Clinical Research

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